Missed malignancy reinforces importance of tracking results

Sep 15, 2017

A delay in the diagnosis of a patient’s cancer due to a missed x-ray result emphasises the importance of keeping track of patient results and robust clinical record keeping.

Missed x-ray report

The patient was a life-long smoker and had been referred to a cardiologist member for management of atrial fibrillation. The doctor had treated the patient for a number of years. After trialling medication unsuccessfully, the cardiologist performed pacemaker implantation and atrioventricular (AV) node ablation.

In accordance with their usual practice, the cardiologist ordered a chest x-ray the day after the procedure to exclude any device-related complications, such as pneumothorax. The cardiologist would usually receive a call from nursing staff relaying the x-ray results. However, on this occasion, the doctor did not recall receiving or reading the report, or whether the results were relayed to them over the phone. The x-ray report was not actioned at the time.

The x-ray report referred to a possible lung nodule and recommended referral for a CT scan.

The lung nodule was eventually discovered over two years later as an incidental finding on a CT coronary angiogram that was performed to exclude ischaemic heart disease, and was found to be malignant. This culminated in a two-and-a-half-year delay in diagnosing the cancer. Subsequently, the patient brought a medical negligence claim against the cardiologist.

Indispensable peer-support

The cardiologist was understandably devastated and contacted Avant immediately. One of our Senior Medical Advisors was able to provide invaluable collegial and emotional support to the member throughout the process.

Ultimately, the civil claim was resolved early in an out-of-court settlement. The claim allowed the member to reflect on their practice and they now check on all of their patients’ results personally.

While the claim did not impact the doctor’s ability to practise, they described the experience as extremely distressing and said it profoundly rocked their confidence both personally and professionally.

Impressed by the professionalism of Avant’s medico-legal team, the member said the Medical Advisor provided all the peer support they needed throughout the process.

‘Thank you so much. I really appreciate the support and advice I received from Avant’s Medical Advisor and the medico-legal team during this time. The professionalism of Avant is wonderful,’ the member said.

Key lessons

Tracking and actioning test results

This case drives home the importance of having a reliable system for dealing with tests and results to support both doctors and practice staff in providing optimal patient care and management.

Your practice or hospital needs to ensure test results are tracked, monitored, communicated to patients and the relevant doctors notified and appropriate recall actions are taken. There should be a centralised system in place for tracking tests and actioning clinically significant tests and results. This should be designed in a way that anticipates that individual cases will require different levels of follow up depending on the clinical significance of the test and/or results.

As a doctor, it’s important when you recommend a test to a patient that you advise them of the reasons for the test, the importance of having it done, arrangements for obtaining the result, and the potential consequences of not having the test. For more information, read our article on tracking clinically significant tests.

Good clinical record keeping

The case also highlights that good clinical record keeping is essential:

  • for good patient care
  • for a proper defence in the event of a claim or complaint against you.

For more information, download our factsheet, Medical records – the essentials.

Dealing with adverse events

Doctors can suffer extreme levels of stress and anxiety when something goes wrong, so looking after yourself after an incident is vital. We outline steps you can take to look after your wellbeing and the open disclosure process.  

More information

If you are subject to a complaint, contact our Medico-legal Advisory Service (MLAS) on 1800 128 268 for medico-legal advice and support, available 24 hours a day, seven days a week in emergencies.

You can also refer to our new handbook for information on how to deal with complaints and obtain CPD points.

Share your view

We welcome your feedback on this article – email the Editor at: editor@avant.org.au